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Key Procedural Steps of Vascular Access

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So let's talk about the key

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procedural steps of vascular access.

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Which vessel is most commonly used for arterial access?

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I'd say the common femoral artery.

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You know, it's really due to its

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large size, its superficial location.

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You know, the common femoral artery

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is pretty much the standard access point

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for the majority of interventional

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endovascular arterial interventions nowadays.

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So when we think about transfemoral arterial access,

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it's the sort of mainstay for vascular access, okay?

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So, the interventional catheterizations

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that sort of occur across the globe,

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the vast majority of them are sort of occurring

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intraluminally through transfemoral arterial access.

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Here we see a case in point of this.

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So for every indication to do a thing, there's

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a contraindication, and as I mentioned before,

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we want to know what are those things that are

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going to move us away from performing an access.

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If a patient is unstable

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to the point whereby, you know, this procedure is

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of no benefit because perhaps, you know, this ball

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that's been thrown out of the window, we're trying

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to jump out of the window to catch it and,

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you know, at some point it's just going to hit the ground.

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So if we are going to actually intervene

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and do good, we want to make sure that, uh,

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we're doing good with the prospects of the

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outcome actually being reversed or optimized.

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If that's not the case, then vascular

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access should not be performed.

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If the patient has coagulopathy, bleeding

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risks are heightened. As we talked

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about before, we can correct that.

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If the patient has type 4, the vascular Ehlers-Danlos

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as it's commonly called now,

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that's a high risk for arterial injury or dissection

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so you want to be kind of clued into that as well.

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So, a patient is ready for her procedure.

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So, how do we, how do we get access?

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So, the Seldinger technique, which was

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developed by Sven Ivar Seldinger in 1953,

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is really the most common vascular access technique.

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We'll attempt to access through the common femoral artery today.

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48 00:01:56,850 --> 00:01:57,620 So let's proceed.

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So what we're marking off

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here is the inguinal ligament.

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And that is really the point in which the common

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femoral artery becomes the external iliac artery.

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Common femoral artery, soft tissues, superficial

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thigh, external iliac artery diving into the pelvis,

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deep pelvis course.

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We're drawing this line from the anterior inferior

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iliac crest or spine to the pubic symphysis.

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That's a nice little sort of demarcation,

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anatomically or landmark-wise, for us to denote

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where this sort of demarcation between common

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femoral and external iliac artery is located.

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So the way we prepare our sterile site is

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by shaving, mechanical cleansing, sterile

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cleansing with either iodine or chlorhexidine.

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Chlorhexidine is, sort of, a little bit,

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sort of stronger, more effective of an antiseptic.

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Then we drape the patient to include

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the sterile areas and exclude the, what?

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Non-sterile areas.

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So as mentioned before, you want to

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anticipate things that can go wrong.

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And here we have a 47-year-old patient that's MRSA

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positive, that had an abdominal endograft placed

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via the common femoral artery access, that developed

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an ulcerating indurated site post-op day four.

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And the question here is, was this

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patient prepped and draped appropriately?

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What went wrong to create the environment for this

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highly unusual indurated site infection to occur?

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So proper prevention and sterile technique is key.

Report

Faculty

Mikhail CSS Higgins, MD, MPH

Director, Radiology Medical Student Clerkships; Director, ESIR

Boston University Medical Center

Tags

Vascular Imaging

Vascular

Ultrasound

Interventional

Iatrogenic

Fluoroscopy

Angiography

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